1986, 02-04 Permit App: 00009594 Roofing, Soffit, Fascia I ,-
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
r s Name AA /? LAST FIRST MI
0/e //ld-d6bl 'L
Project Address(Street Name&Number) Zip
In l V'1114/CL o Lf t.
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent 6.1/671.
Address
51a.n dye n -h/ C�hs7. E� /C51°7 4 ,72z/7
Ci y Phone
po C r e. Stat, � F47 26
Zip J� ay' (`7 2- )- ‘./O/
Contact (//t�// License Number(Required) Business Phone
51"AA/L-o€ /6-g 4,i A/ 6'61-vn -ems
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )yy�
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